Diabetes structural education for children and their families: labour intensive, poorly attended, and no improvement in blood sugars


familyNICE want to see structural education for all new diabetics but particularly children and their families. Sadly the end results sometimes doesn’t seem to justify the effort put in. The wrong focus on eating lots of starch we wonder? Here is the abstract of one teams considerable efforts with the full paper here: :http://drc.bmj.com/content/3/1/e000065.full?sid=90e5f16a-f3de-4a5d-94dc-c57e973c4587

Implementing a structured education program for children with diabetes: lessons learnt from an integrated process evaluation | BMJ Open Diabetes Research & Care <!– [if lt IE 10]>http://drc.bmj.com/sites/all/themes/highwire/axon/js/media.match.min.js<![endif]–>


Background There is recognition of an urgent need for clinic-based interventions for young people with type 1 diabetes mellitus that improve glycemic control and quality of life.

The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) is a structured educational group program, using psychological techniques, delivered primarily by diabetes nurses.

Composed of four modules, it is designed for children with poor diabetic control and their parents. A mixed methods process evaluation, embedded within a cluster randomized control trial, aimed to assess the feasibility, acceptability, fidelity, and perceived impact of CASCADE.


Methods 28 pediatric diabetes clinics across England participated and 362 children aged 8–16 years, with type 1 diabetes and a mean glycosylated hemoglobin (HbA1c) of 8.5 or above, took part. The process evaluation used a wide range of research methods.


Results Of the 180 families in the intervention group, only 55 (30%) received the full program with 53% attending at least one module. Only 68% of possible groups were run.

Staff found organizing the groups burdensome in terms of arranging suitable dates/times and satisfactory group composition. Some staff also reported difficulties in mastering the psychological techniques.

Uptake, by families, was influenced by the number of groups run and by school, work and other commitments. Attendees described improved: family relationships; knowledge and understanding; confidence; motivation to manage the disease. The results of the trial showed that the intervention did not significantly improve HbA1c at 12 or 24 months.


Conclusions Clinic-based structured group education delivered by staff using psychological techniques had perceived benefits for parents and young people. Staff and families considered it a valuable intervention, yet uptake was poor and the burden on staff was high. Recommendations are made to inform issues related to organization, design, and delivery in order to potentially enhance the impact of CASCADE and future programs.

Current Controlled Trials ISRCTN52537669.

Key messages

  • The Child and Adolescent Structured Competencies Approach to Diabetes Education (CASCADE) structured education program is perceived by young people and parents who attend as having benefits but practical challenges associated with attendance result in low uptake.

  • Staff are positive about the potential of the program but organizational aspects are unacceptably burdensome.

  • CASCADE is potentially deliverable to families as part of routine care and could be a useful intervention. However, improvements in clinical and administrative support, staff training, program content, and service structures are required to ensure fidelity to the program and feasibility and acceptability to key stakeholders.

    1. Mary Sawtell1,
    2. Liz Jamieson2,
    3. Meg Wiggins3,
    4. Felicity Smith2,
    5. Anne Ingold3,
    6. Katrina Hargreaves3,
    7. Meena Khatwa3,
    8. Lucy Brooks4,
    9. Rebecca Thompson5,
    10. Deborah Christie5

    Author affiliations

    1. 1Social Science Research Unit, UCL Institute of Education, London, UK

    2. 2Department of Practice and Policy, UCL School of Pharmacy, London, UK

    3. 3Social Science Research Unit, Institute of Education, London, UK

    4. 4Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK

    5. 5University College London Hospitals NHS Foundation Trust, London, UK
    1. Correspondence to Mary Sawtell; m.sawtell@ioe.ac.uk

3 thoughts on “Diabetes structural education for children and their families: labour intensive, poorly attended, and no improvement in blood sugars”

  1. Looks a bit like reinventing the wheel, and putting one less corner on it.

    Over the years I’ve read numerous criticisms of DAFNE and similar programmes, while many Type 1s praised the online course available from Bournemouth Diabetes and Endocrinology Centre, which was even seen to be world class in quality. Might this be something they could learn from?


  2. I did the online Bournemouth Course years ago and it was very high carb. I wrote to the consultant director and suggested we collaborate on a low carb one, or at least that he put the low carb options in, rather than the fish, chips, mushy peas and two pints of lager meals they had in it. He declined. He then left to work in Brussels and eventually published his own low carb diabetes book. He had to LEAVE THE NHS before he felt safe enough to publish his low carb proclivities.


    1. Hehe, no surprise there then!

      AFAICR the main criticism of DAFNE etc. was the emphasis on NOT doing postprandial testing so you couldn’t see the harm all the carbs were doing.

      I wonder if Partha Kar might be able to improve things? Or someone else who doesn’t think Richard Bernstein wrote West Side Story (not my joke) or even some of the patients (Type 1Grit etc.) who have better A1cs than many “nondiabetics” . . .

      Liked by 1 person

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